Investigations: Don't Miss a Step
GuideOne Risk Resources for Health Care
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W. Des Moines, IA 50265-3538



Investigations: Don't Miss a Step

Periodically, there are circumstances in every assisted living facility that require investigations. These include, but are not limited to: general tenant grievances, employee misconduct, compliance issues related to care or reimbursement, misapplication of tenant funds or property, as well as any allegation or suspicion of tenant mistreatment, neglect, abuse and injuries of unknown origin.

While most facilities have policies and procedures in place to address these types of circumstances, they can sometimes be inadequate if the investigator is not sure of which facts to collect and how to analyze and document. To assist your facility, the following are common items that often get overlooked when an investigation is performed.

Staff Education

  • Upon orientation all staff are trained and reminded annually to immediately report incidents to their supervisor, especially those involving any allegation of abuse (theft, drug theft, physical, sexual, verbal, etc.).
  • Staff are made aware of the definition of injury or unknown origin, including:
    • Bruising;
    • Skin tears;
    • Fracture;
    • Head injury; and
    • Burns.
  • All incidents involving tenants are investigated by a nurse or designee, regardless if the tenant receives assistance or not.
  • State reporting criteria are followed within timeframes allowed and by the most expeditious means possible.

Incidents Involving Resident Injury

  • A confirmed Incident Report, including the following, is completed:
    • Who was involved;
    • Date of incident;
    • Time of incident;
    • Factual description of the incident;
    • Location of the incident;
    • Notifications of nurse, physician, family/legal representative, etc.;
    • Description of injury;
    • Action taken (First Aid, contacting 911 or nurse directive); and
    • Signature of the individual completing the report.
  • The Incident Report workflow process is completed in a timely manner:
    • From staff member to the RN;
    • From RN to next designated individual and/or agency; and
    • For purposes of tracking and trending incidents.
  • Confirm Witness Reports/Statements were completed in a timely manner.
  • Reviewed the circumstances surrounding the incident:
    • Environmental (signs of incident), as indicated;
    • Staff response; and
    • Potential contributing factors to the incident.
  • Reviewed the tenant's chart, including recent nurse notes, evaluations, service plan, medication administration record (MAR), physician orders and previous incident history.
  • Determined what assistance was identified on the service plan (assisted with ambulation, etc.).
  • Determined if the program is culpable for the injury (wet floor, ice on sidewalk, ill repaired flooring, cord across floor, etc.).
  • Reviewed facility policies and procedures to determine if staff followed appropriate protocols.
    • If a major injury occurred, did staff recognize the need for consultation with the attending physician, designee of the physician or physician extender? Was admission to a higher level of care for treatment completed in a timely manner?
  • Other factors investigated, as needed:
    • X-ray reports;
    • Hospital admission diagnosis;
    • Focused interviews or shift/facility-wide interviews;
    • Family interviews and statements;
    • Photographs;
    • Timeframe considerations; and
    • Operation and location of emergency pendant system.

Dependent Adult Abuse Reporting

  • If the incident involves a suspected staff member, he or she has been separated from tenants. Typically, a program suspends the employee pending an outcome of the investigation.
  • Police contacted, as indicated.
  • Checked the staff file for completed:
    • Background checks, as required;
    • Dependent Adult Abuse training, as required;
    • Staff training, as required (ADL assistance);
    • Any previous disciplinary actions or write-ups; and
    • Potential for notification to a licensing board or registering agency, as applicable.

Theft of Personal Property and Medications

  • Determined if the tenant thought they lost item or are they stating specifically it was stolen.
  • For personal property, noted a description of the item, including a picture, if available.
  • Determined when the object was last seen and who had access to it (staff, family, visitors, etc.).
  • For medications, reviewed the following:
    • Narcotic count sheets;
    • Pharmacy records – who recently ordered, requested an increase or additional narcotics; and
    • MAR and PRN usage – look for a common staff name that appears with PRN administrations.
  • Reviewed literature and training on the detection of an impaired employee (related to potential substance abuse).

Sexual Assault

  • Physician notification;
  • Contacted police and sought emergency room evaluation/rape kit;
  • Secured items in the tenant's incident location;
  • Determined recent changes in tenant's behavior;
  • Determined any visitors and/or visits outside of the facility; and
  • Checked sex offender registry for staff, tenants, etc.


  • Determined the following:
    • Who found the tenant;
    • Where the tenant was found;
    • Time and date the tenant was found;
    • Outside weather and temperature;
    • What the tenant was wearing (head to toe);
    • What the tenant was last known to be doing;
    • The tenant's behavior that day or prior to the incident;
    • Condition of resident upon return (vital signs, injuries, etc.);
    • Knowledge of the tenant being outside; and
    • Did an alarm sound? If so, did staff respond appropriately?
      • What was the resident doing when the door alarmed?
  • Determined if door alarms were operational
    • Check the last time door alarms were serviced to ensure proper operation.
  • Reviewed policy for staff response to door alarms.
  • Reviewed policy for elopement/missing tenant.

Additional resources can be found at

Ruden, K. and Hejda, S. (2014, March 19). Self reporting – how to investigate issues in assisted living.


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